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Authors:
Gregary D. Marhefka, MD
Citation:
Consultant. 2016;56(3):222-232.
ABSTRACT: Acute hypertensionblood pressure greater than 180/120 mm Hg
can be classified as either hypertensive urgency or hypertensive
emergency. Hypertensive urgency has no associated target organ damage,
whereas hypertensive emergency can feature neurologic, aortic, cardiac,
renal, hematologic, and/or pregnancy-related damage. Little evidence-based
research exists about treatment. Intravenous antihypertensive
pharmacotherapy is indicated only for hypertensive emergency, with the use
of specific agents tailored to the type of organ damage. Several US and
European guidelines provide recommendations for the diagnosis and
management of hypertensive urgency and hypertensive emergency. This
review summarizes what is known about managing hypertensive urgency and
emergency, with an emphasis on guideline-directed therapy.
"There is some truth in the saying that the greatest danger to a man with a
high blood pressure lies in its discovery, because then some fool is certain to
try and reduce it, said British physician John Hay, MD, in 1931.1 We have
learned a great deal about acute hypertension in the 85 years since Dr Hay
was quoted. Nevertheless, despite dramatic advances in modern medicine, a
significant void still exists in its evidence-based management.
HYPERTENSIVE URGENCY
The JNC 7 notes, Unfortunately, the term urgency has led to overly
aggressive management of many patients with severe, uncomplicated
hypertension.5 The American College of Emergency Physicians (ACEP) 2013
policy statement6 chooses the phrase asymptomatic elevated blood
pressure rather than hypertensive urgency. The colleges policy statement
notes that most clinical trials use a blood pressure above 180/100 mm Hg, but
they chose to define asymptomatic elevated blood pressure as that consistent
with JNC 7s stage 2 hypertension, 160/100 mm Hg or greater. The 2013
hypertension management guidelines from the European Society of
Hypertension (ESH) and the European Society of Cardiology (ESC) define
hypertensive urgency as blood pressure greater than 180/120 mm Hg without
acute organ damage7 (Table 1).
Uses phrase asymptomatic elevated blood pressure instead of hypertensive
a
urgency.
Grassi and colleagues10 studied 549 ED patients (average age 59 years; 51%
men) with asymptomatic blood pressure greater than 180/100 mm Hg, without
preexisting cardiovascular, cerebrovascular, or renovascular disease. All
patients were placed in a quiet room for 30 minutes of rest; 175 patients
(31.9%) had a significant reduction in blood pressure of at least 20/10 mm Hg
to below 180/100 mm Hg with rest alone. The remaining patients then were
given oral amlodipine, perindopril, or labetalol (decided by the attending
physician of record), of which 296 of 394 (75%) had a significant reduction in
blood pressure of at least 20/10 mm Hg to below 180/100 mm Hg. There were
no complications noted in any of the groups at follow-up within 48 to 72 hours.
These studies demonstrate the safety and importance of rest and oral
antihypertensive therapy with close outpatient follow-up for the treatment of
hypertensive urgency.
HYPERTENSIVE EMERGENCY
The one diagnosis that mandates an immediate rather than gradual reduction
to normal blood pressure levels is acute aortic syndrome (Table 1).12,13
Neurologic Damage
Aortic Damage
The 2010 American College of Cardiology Foundation (ACCF) and AHA task
force guidelines for the diagnosis and management of thoracic aortic disease
recommend reducing the velocity of ventricular contraction (dP/dt max), the rate
of ventricular contraction, and the blood pressure with -blockers, targeting a
heart rate of less than 60 beats/min and a systolic blood pressure between
100 and 120 mm Hg while maintaining adequate organ perfusion.12
The 2014 ESC guidelines on the diagnosis and treatment of aortic diseases
recommend treatment with IV -blockers to reduce heart rate and lower
systolic blood pressure to 100 to 120 mm Hg (Table 1).13 It is essential to start
with a negative inotrope such as esmolol, because starting with vasodilator
therapy actually may increase dP/dt and therefore the sheer stresses on the
acutely injured aorta, leading to dissection progression and rupture. After -
blockers have been maximized, pure vasodilator medications such as
nicardipine, clevidipine, nitroprusside, or nitroglycerin may be needed to
achieve the target blood pressure (Table 3).
Acute aortic syndromes also are unique because, unlike with other
hypertensive emergencies, the goal is to reduce systolic blood pressure to
100 to 120 mm Hg as quickly as possible, not only by 25% in the first hour or
so. This requires strict ICU-level monitoring for sequelae of overly rapid
reduction of blood pressure that can occur due to potential loss of
microvasculature autoregulation at suddenly lower blood pressures. If this
occurs, finding a median blood pressure that reduces dP/dt on the injured
aorta but allows other organ perfusion is individualized by patient.
Cardiac Damage
Acute hypertension sometimes can be associated with acute MI, acute heart
failure, or acute pulmonary edema. In the differential diagnosis of ST segment
elevation MI (STEMI), one must always remember the possibility of acute type
A aortic dissection with the dissection flap occluding right coronary artery
flow or, more rarely, left coronary artery flow.19
For hypertensive emergency with acute MI not associated with type A aortic
dissection, treatment with nitroglycerin is indicated, along with goal-directed
therapies for non-ST segment elevation MI or STEMI (Table 3). Nitroglycerin
should not be used in cases of suspected right ventricular infarction or if the
patient recently has taken a phosphodiesterase type 5 inhibitor for erectile
dysfunction within the preceding 24 to 48 hours.
Per the 2013 ACCF/AHA guideline for the STEMI management,20 fibrinolytic
therapy is absolutely contraindicated in severe uncontrolled hypertension
greater than 180/110 mm Hg that is unresponsive to emergency medical
therapy (Table 3). If there is severe hypertension greater than 180/110 mm Hg
at the time of admission, fibrinolytic therapy is relatively contraindicated
(Table 1). In addition to IV nitroglycerin, an IV -blocker (eg, metoprolol) also
is reasonable for ongoing hypertension or ischemia in the absence of acute
heart failure, low cardiac output, or bradyarrhythmias. Nitroprusside should be
used carefully if at all in the setting of acute coronary syndrome due to its
potential for inducing coronary steal. The true clinical significance of this
potential complication is unknown.21
Renal Damage
Hematologic Damage
Pregnancy
While monitoring the fetus, the recommended first-line agents are IV labetalol,
IV hydralazine, or oral nifedipine (Table 3). Magnesium sulfate is not an
antihypertensive medication but is used to prophylactically reduce seizure
risk in preeclampsia or to treat seizures in eclampsia. Hydralazine can induce
maternal hypotension. Labetalol can result in neonatal bradycardia and
should be avoided in patients with heart failure or asthma. Nifedipine can lead
to maternal tachycardia and hypotension.11
CONCLUSION
The optimal IV medication and the rapidity with which optimal blood pressure
is achieved depend on the type of end-organ damage.
4. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for
the management of high blood pressure in adults: report from the panel
members appointed to the Eighth Joint National Committee (JNC
8). JAMA. 2014;311(5):507-520.
5. Chobanian AV, Bakris GL, Black HR, et al; National High Blood Pressure
Education Program Coordinating Committee. Seventh report of the Joint
National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
6. Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM; American College of
Emergency Physicians Clinical Policies Committee. Clinical policy:
critical issues in the evaluation and management of adult patients in
the emergency department with asymptomatic elevated blood
pressure. Ann Emerg Med. 2013; 62(1):59-68.
9. Levy PD, Mahn JJ, Miller J, et al. Blood pressure treatment and
outcomes in hypertensive patients without acute target organ damage:
a retrospective cohort. Am J Emerg Med. 2015;33(9):1219-1224.
16. EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke
Council, Council on Cardiovascular Nursing, Council on Peripheral
Vascular Disease, and Council on Clinical Cardiology. Guidelines for the
early management of patients with acute ischemic stroke: a guideline
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17. Keith NM, Wagener HP, Kernohan JW. The syndrome of malignant
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as blurry vision in a patient with hypertensive chorioretinopathy. Int J
Emerg
Med. 2015;8(13). http://intjem.springeropen.com/articles/10.1186/s12245-
015-0063-6. Accessed February 18, 2016.
19. Luo JL, Wu CK, Lin YH, et al. Type A aortic dissection manifesting as
acute myocardial infarction: Still a lesson to learn. Acta
Cardiol. 2009;64(4):499-504.
20.OGara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for
the management of ST-elevation myocardial infarction: a report of the
American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-e425.
21.Hottinger DG, Beebe DS, Kozhimannil T, Prielipp RC, Belani KG. Sodium
nitroprusside in 2014: a clinical concepts review. J Anaesthesiol Clin
Pharmacol. 2014;30(4):462-471.
22.Derhaschnig U, Testori C, Riedmueller E, Hobl EL, Mayr FB, Jilma B.
Decreased renal function in hypertensive emergencies. J Hum
Hypertens. 2014; 28(7):427-431.